Societal beliefs about pain may be more balanced than previously thought. Results of the Guernsey pain survey

Background Musculoskeletal pain is multidimensional and associated with significant societal impact. Persistent or chronic pain is a public health priority. A step towards high-value care is a contemporary understanding of pain. While pain-related knowledge has been examined in specific conditions (e.g. neck pain) knowledge of the public’s broader understanding regarding musculoskeletal pain per se, warrants investigation. This study examined the public’s knowledge and beliefs regarding musculoskeletal pain and pain management. Methods This observational cohort study was conducted in Guernsey (January 2019-February 2020). Participants (n = 1656; 76.0% female) completed an online questionnaire capturing: demographics, pain experience, work absenteeism, understanding of pain and pain management, multidimensional influences, physical activity, pain catastrophising and healthcare decision-making. Statements were deemed true/false/equivocal and mapped to biopsychosocial/biomedical/neutral perspectives based upon contemporary literature. Descriptive statistics were analysed for each statement. Participants’ responses were examined for alignment to a contemporary viewpoint and themes within responses derived using a semi-quantitative approach modelled on direct content analysis. Comparisons between participants with/without pain were examined (χ2-squared/Wilcoxon Rank Sum test). Results Within the cohort 83.6% reported currently experiencing pain. The overarching theme was perspectives that reflected both biomedical and contemporary, multidimensional understandings of pain. Sub-themes included uncertainty about pain persistence and evidence-based means to reduce recurrence, and reliance upon healthcare professionals for guiding decision-making. Compared to those with pain, those without had a greater belief that psychological interventions may help and lower pain catastrophising. Conclusions Participants’ understanding of pain demonstrated both biomedical and multidimensional pain understanding consistent with elements of a contemporary understanding of pain. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-023-07088-0.

• Highest educational level attained (primary school, high school, trade / vocational qualification, university degree, postgraduate degree).
• Participants were asked whether they were an exercise prescriber (e.g.personal trainer), complementary / alternative therapist or registered healthcare professional.

Pain experience
• Participants were asked whether they currently had any musculoskeletal pain or had ever experienced pain lasting three months or more.They were also asked whether they had had pain lasting three months or more during the past year, and if so how much this pain had interfered with daily activities (A lot, Quite a bit, A little, Not at all).
• Taken from the Orebro Musculoskeletal Pain Screening Questionnaire [53] participants were asked, "How many days of work have you missed because of pain in the last 12 months?"

Understanding of pain
Participants indicated their beliefs (true, false, unsure) regarding several statements.
The following statements were taken from the Revised Neurophysiology of Pain Questionnaire [16]: • Pain only occurs when you are injured or at risk of being injured.
• Persistent pain means that an injury hasn't healed properly.
• The body tells the brain when it is in pain.
• Pain occurs whenever you are injured.
• When you injure yourself, the environment that you are in will not affect the amount of pain you experience, as long as the injury is exactly the same.
• The brain decides when you will experience pain.
The following two statements were taken from the Avoidance-Endurance Questionnaire [35]: • When I have pain I think to myself "don't make such a fuss"

• When I have pain I carry on doing what I'm doing no matter what
The following statements were developed to further explore public beliefs about pain: • There is always a simple explanation for why someone has pain • Culture • Amount of tissue damage or injury (e.g.disc bulges, arthritis, tendon strains etc.) • Whether you are male of female

• Education level
• Other health problems (e.g.heart disease, diabetes, lung conditions etc) • Alcohol/drug consumption

Physical activity and pain
Three questions were taken from the Fear-Avoidance Beliefs Questionnaire [91].Participants were asked to indicate their level of agreement with the following statements, using a seven=point scale ranging from, "Strongly disagree," to, "Strongly agree." • Physical activity makes pain worse.
• Physical activity might harm my body if I am in pain.
• I should not do physical activities which (might) make pain worse.

Pain Catastrophising Scale (PCS)
Pain catastrophising was assessed using the full Pain Catastrophising scale (PCS), a valid and reliable [84] questionnaire examining a person's thoughts and feelings in terms of magnification, rumination, and helplessness about pain.On a 0 -4 scale participants indicate the frequency at which they experience these different types of catastrophic thoughts described in 13 statements, giving a total score of 0 -52 points, with higher scores reflecting greater pain catastrophising.

Healthcare decision making
Participants were asked, "What influences your decisions to have certain types of treatments?" Participants ranked the following statements in order of importance with "1" being the most important.They were able to indicate that an answer was not applicable to them.
• Recommendations from friends / family Respondents' beliefs about physical activity and pain (n=1122).Data are presented as n (%). .03 Physical activity might harm my body if I am in pain I should not do physical activities which (might) make pain worse .30 STD: Strongly disagree; D: Disagree: SMD: Somewhat disagree; N: neither agree nor disagree; SMA: somewhat agree; A: Agree; STA: Strongly agree Questions taken from the Fear-Avoidance Beliefs Questionnaire [92].*p-value reflects difference between pain and no pain subgroups.
Results from the Pain Catastrophising Scale including comparisons between the pain subgroup and the no pain subgroup (n=1110).Data are presented as n (%) unless otherwise specified. .001 .01 There

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Most pain gets better • Once you have pain, you're always likely to have pain • More pain means more tissue damage (i.e.damage to joints, nerves, tendons or muscles) There is always tissue damage to explain pain • It is possible to have tissue damage but no pain • Findings on scans like arthritis and disc bulges are always associated with pain • An increase in pain is an indication that you should stop doing what you're doing until the pain decreases • Pain may mean something is out of place • If pain is not associated with injury or tissue damage it must be psychological • Pain is abnormal • Pain means you aren't healthy • Pain is usually caused by physical overuse or excessive strain • Pain is usually caused by work or by an accident at work • Full pain relief is necessary before returning to work, sport or other daily activities • Tests like MRI scans, x-rays and ultrasound imaging are critical to identify the source of pain • The source of pain must always be identified for adequate pain treatment to occur • It is possible to have the right treatment for pain without having tests like MRI scans, x-rays or ultrasound imaging • When I am in pain my family/partner should look after me Understanding of pain treatment Participants indicated their beliefs (true, false, unsure) regarding the following statements developed to explore public beliefs about pain treatment: • It is important to rest when you have pain • It is important to stay active when you have pain • It is important to gradually increase your activity when you have pain • If you experience pain, you should just keep pushing through • It is possible to manage pain well yourself • It is important to seek professional advice for pain care • It is important to seek treatments (medications, injections, surgery, hands-on treatments) from professionals to get pain relief The following three statements were replicated for several interventions (medication, injections, surgery, exercise, psychological treatments, "hands-on" therapies): • Medications can be helpful for treating pain • Medications are always helpful for treating pain • Medications are never necessary for treating pain • Stronger medications are always better for pain relief • Surgery should only be considered as a final option when other treatments have not worked • There is always some surgical procedure or medication that will get rid of pain • You should be very careful exercising when you have pain • Stretching is always an effective exercise for pain • Good core stability is key to managing pain • It is always important to maintain good alignment when exercising, especially if you have pain • Good advice can be sufficient pain care • Understanding how pain works is an effective pain treatment • Relaxation and mental distraction are good ways of treating pain • Psychological treatments (talk therapies, stress management, mindfulness) should only be used for pain relief when nothing else has worked • Addressing mood and stress/anxiety is important for good pain care • Physical therapies (physiotherapy, osteopathy, chiropractic) should always include 'hands-on' treatments for pain relief • It is important to treat underlying lifestyle factors for pain relief (e.g.sleep, stress, work habits, exercise, diet) • I am usually willing to change my habits and behaviours to improve my health and pain care • Future episodes of pain can be reduced or avoided by avoiding aggravating activities • Future episodes of pain can be reduced or avoided through exercise • Future episodes of pain can be reduced or avoided by getting regular 'hands-on' treatments like massage or manipulation • Future episodes of pain can be reduced or avoided by addressing lifestyle factors like sleep, weight and stress • Future episodes of pain cannot be avoided Influence on pain Participants were asked to indicate whether they believe the following factors (which in the literature are associated with musculoskeletal pain) influence pain.: • Mood • Beliefs about injury and tissue damage • Physical activity levels • Posture and alignment (e.g.spinal posture, leg alignment, foot posture) Beliefs about pain • Weight • Stress (at home, at work etc) • Access to appropriate healthcare • Ergonomics (e.g.work set up and practices)
[20]ammatory conditions; post-operative pain; whilst false for persistent pain It is important to stay active when you have pain True BPS[20]It is important to gradually increase your activity when you have pain True N [54] If you experience pain, you should just keep pushing through False N It is possible to manage pain well yourself True N [64] It is important to seek professional advice for pain care Equivocal N May be credible digital information accessible if appropriate and no red flags.It is important to seek treatments (medications, injections, surgery, hands-on treatments) from professionals to get pain Exercise is never necessary for treating pain False N You should be very careful exercising when you have pain Equivocal Med May be interpreted differently -e.g.true for acute pain following tissue trauma, whilst false for persistent pain.'Hands-on' therapies (massage, manipulation) can be helpful for treating pain True Med [31; 73] 'Hands-on' therapies are always helpful for treating pain False Med 'Hands-on' therapies are never necessary for treating pain False N [31; 73] Physical therapies (physiotherapy, osteopathy, chiropractic) should always include 'hands-on' treatments for pain relief *p-value reflects difference between pain and no pain subgroups.
Physiotherapy Evidence Database; NHS: National Health Service (UK): NICE: National Institute of Clinical Excellence *p-value reflects difference between pain and no pain subgroups Guernsey sociodemographic data (2019-2020) to facilitate comparison with other jurisdictions.Age and sex distribution of Guernsey population at March 2019 1 :